We investigated the diagnostic efficacy of computed tomography (CT) for proximal deep vein thrombosis (DVT). The ratio of femoral/crural muscle swelling (affected/unaffected) was estimated by determining the femoral/crural muscle area on CT scans (FMR: femoral muscle ratio, CMR: crural muscle ratio). This examination is quick and safe and provides an easy access tool for evaluating patients with limb swelling, it is suitable especially for primary care physicians. The aim of the present study was to establish the threshold for screening proximal DVT and determine the diagnostic efficacy of CT for distal DVT. The FMR threshold for proximal DVT was 1.2; sensitivity, specificity, accuracy, and predictive value of this test were 80%, 100%, 85% and 100%, respectively. The CMR threshold for distal DVT was 1.15; sensitivity, specificity, accuracy, and predictive value of this test were 83%, 80%, 81% and 71%, respectively. Thus, we propose use of the FMR/CMR as a strategy for diagnosis of DVT in Japan.

Tumor invading into the inferior vena cava (IVC) is found in advanced retroperitoneal malignant tumor, especially in renal cell carcinoma (RCC). We retrospectively reviewed surgical strategy for 30 cases of RCC and a case of Wilms’ tumor (n=31) with inferior vena caval invasion, which were performed from 1980 to 2001. Cephalad extension of intracaval tumor was categorized as infrahepatic level in 13 cases, retrohepatic in 9 cases, suprahepatic in 5 cases and intraatrial in 4 cases with RCC. Radical nephrectomy with tumor removal was performed in 19 cases and IVC was totally resected in 11 cases. Partial cardiopulmonary bypass (CPB) with normothermia and noncirculatory arrest was used in 4 patients. Pringle’s maneuver was applied in 8 patients; infrarenal abdominal aortic crossclamping was applied in 8 patients to maintain systemic blood pressure. The complication, which attributed to operative death was intraoperative pulmonary embolism in one patient, other complications included ileus in 5 patients, deep venous thrombosis in 2 patients, acute renal failure in 2 patients, cholecystitis in one patient and disseminated intravascular coagulation in one patient. Average survival duration was 37.3 ± 44.1 months (range: 3.9-180 months) in patients with RCC and the 5-year survival rate was 42.2 %. Surgical strategy and indication for the partial CPB were decided by the cephalad extension of tumor thrombus. When the tumor thrombus extended to the suprahepatic vein, cross-clamping of IVC and Pringle’s maneuver were performed. If the systemic blood pressure decreased below 80 mmHg, infrarenal abdominal aortic cross-clamping was applied. A temporary IVC filter insertion or plication above the hepatic vein was performed prior to hepatic mobilization in order to prevent pulmonary embolism. Surgical management could occasionally provide a long-term survival to patients with RCC even if the tumor thrombus was extended into the IVC. Therefore, it is recommended to accomplish radical nephrectomy and tumor thrombectmy with or without caval resection in patients with RCC and the IVC invasion.

[Purpose] The purpose of this study was to determine the distribution of venous reflux in the deep venous system, superficial venous system and IPVs, and to examine the pathophysiology of primary varicose veins.

[Patients and Methods] One thousand two hundred sixty four patients (356 men, 908 women, mean age 58±11years) with 1606 limbs with primary varicose veins were examined with duplex scan between 1999 January and 2002 July. 417 limbs (26%) had skin changes and belonged to C4-6 of CEAP classifications.

They were divided into four groups according to reflux of the saphenofemoral junction (SFJ) and saphenopopuliteal junction (SPJ). Distribution of deep venous reflux and incompetent perforating veins and clinical symptoms and signs were compared among four groups.

[Results] 1205 limbs (75%) had reflux in SFJ (SFJ+). 205 limbs (13%) had reflux in SPJ (SPJ+). 166 limbs (10%) had reflux in SFJ and SPJ (SFJ+SPJ). 30 limbs had no reflux (N). 266 limbs (16%) had deep venous reflux. Limbs with deep vein reflux account for 30% in SFJ+SPJ (p<0.001). IPVs were more prevalent in SFJ+ and SFJ+SPJ than in SPJ+ (p<0.001). Direct IPVs (Dodd’s, Boyd’s, Cockett’s and paratibial IPV) account for 81% of all IPV. Prevalence of deep venous reflux and IPVs (especially Cockett’s IPVs) were higher in subjects of C4-6 than of

C2-3.

[Conclusions] It is important to examine prevalent IPVs effectively as well as the saphenous vein and deep venous system for preoperative duplex scanning of primary varicose veins. There are strong correlations between worsening clinical features and prevalence of venous refluxes in the superficial veins, the deep veins, and IPVs. Venous reflux aggravates venous hemodymanics in the legs with varicose veins. Direct IPVs such as Cocckett’s IPVS is important to treat primary varicose veins.

Two cortical veins occlusion in rats is less invasive, clinically relevant and reproducible model which is suitable forthe pathophysiology of penumbra-like tissue. We here examined sequential changes of Bcl-2 family proteins and TUNEL staining in this model.

Twenty-seven male Wister rats were used. Two adjacent cortical veins were occluded photochemically by using rose bengal dye. The rats were submitted to perfusion fixation at 4, 12 hours and 1,2,4,7 days after the vein occlusion(each=4). Immunohistochemical analysis of Bcl-2 family protein and TUNEL staining were performed to examine the relation with the process of cell death in the penumbra-like condition in venous circulation disorders. Three animals served as sham-operated control.

TUNEL positive cells began to appear at 1 day after the vein occlusion with the peak at 2～4 days and localized in the center and around infarction. Bax protein began to appear immunohistochemically at 4 hours around the ischemic lesion. Its peak was 1 day, and they were scattered around the infarction. On the other side, Bcl-2 protein was negative from the early phase to 4 days.

Based on the results of this study, apoptosis is related to the pathological development of venous infarction.

The safety and tolerability of polidocanol after a single dose were assessed in 19 patients with varicose veins of the lower extremity. Pharmacokinetic parameters were also measured in 5 patients. Six subjects were treated with a dose of 0.11-0.47 mg/kg (low dose group), 6 with that of 0.56-1.38 mg/kg (intermediate dose group), and 7 with that of 1.58-2.00mg/kg (high dose group).

None of the subjects developed any treatment-related systemic adverse events. Treatment-related local adverse events included intravariceal thrombosis, local pain, venous pain, and redness, which were resolved in all patients with a surgical with the passage of time. Laboratory tests (hematology, biochemistry, and urinalysis) showed abnormal changes in 6 subjects. Those changes were within the normal range and had no clinical significance.

After an injection of polidocanol with 1.62-1.88 mg/kg, the pharmacokinetic parameters were measured as follows: maximum plasma concentration 6.645-10.319µg/ml and half life period 0.94-1.27 hours. Polidocanol was safe and well tolerated at doses up to 2 mg/kg in patients with varicose veins of the lower extremity.

The purpose of the study was to assess venous-valve movement and venous flow in the lower extremity in connection with respiration. We performed ultrasonographic study of right lower limb in 10 healthy male volunteers. Each subject was placed supine in reverse-Trendelenburg’s position and respiration was monitored during examination. In each examination, both abdominal respiratory method (using diaphragm movement; AbM) and thoracic respiratory method (using thoracic enlargement; ThM) were performed. The valve movement and the blood flow in the right femoral vein were analyzed by B-mode and pulse Doppler images, respectively, in connection with respiratory methods. Usually, the valve was observed to open and close at the start of expiration and inspiration, respectively, and the flow has been observed during expiration when AbM was used (9/10). When ThM was used, no closure of the valve was observed and the flow has been observed without apparent pause in most cases (6/10, P<0.05). The effect of respiration on the valve movement and the venous flow was considered to be significant. The flow pattern may largely depend on the respiratory method and expiration may have an effect to accelerate the venous flow in some degree when AbM is used.

We experienced a case of emergency pulmonary embolectomy for acute pulmonary embolism after venous ligations for primary varicose veins. A 58-year-old woman visited our outpatient clinic for left short saphenous type varicose veins with heaviness and swelling in her legs, and was treated with duplex scan oriented venous ligations. She noticed dyspnea on the fifth POD and came to the hospital on the seventh POD. Duplex scan examination showed thrombus at the stump of the SPJ and deep vein thrombosis in the left leg, and echocardiography revealed the floating thrombus in the right atrium and the right ventricle dilatation. Contrast enhanced CT scanning identified a shadow defect by embolus in a pulmonary artery. Under the diagnosis of pulmonary embolism due to deep venous thrombosis of the left leg, emergent embolectomy was performed and IVC filter was also inserted. The patient recovered uneventfully.

The frequency of postoperative deep venous thrombosis after surgery for varicose veins in our hospital is 0.1%, and it is thought that this is a very rare case accompanied with life-threatening pulmonary embolism. It is important to construct the emergency system for severe complications such as pulmonary embolism, because day surgery will be done broadly and less invasive surgery such as venous ligations involves risk of DVT.

We report a case of Lemierre’s syndrome that is an uncommon septic thrombophlebitis of the internal jugular vein. A 77-year-old woman suffered from pain and swelling of the left side of her neck was admitted into our hospital. Blood chemistry findings showed an inflammatory and hypercoagulable states.

Contrast-enhanced computed tomography and magnetic resonance imaging of the neck revealed the presence of an occlusive thrombosis of the left internal jugular vein. Her symptoms and the jugular vein thrombus showed remarkable improvement after administration of antiimflammation and anticoagulation therapy. No pulmonary embolism or other metastatic infection were observed. It was suggested that accurate diagnosis during early treatment was essential to obtain a successful prognosis for Lemierre’s syndrome.

A 51-year-old man who had shunt trouble over 20 times after the introduction of hemodialysis was placed arteriovenous access bridge graft in the right lower extremity on February, 2000. A looped bridged fistula was made with expanded polytetrafluoroethylene (ePTFE) in the right thigh. On May, 2001, he presented with edema, pigmentation and ulcer of the right lower extremity. Maintained hemodialysis was difficult due to the elevation of venous pressure. Venogram revealed the occlusion of the right iliac vein. He was performed the endovascular treatment including PTA and expandable metallic stenting for the occluded right iliac vein after introduction of transient IVC filter. Swelling of the right lower extremity was promptly improved and reduction of the venous pressure grade was achieved. 20 months after the treatment, the patency of the right iliac vein was maintained. Percutaneous treatment including stent placement is safe and effective to preserve the functioning dialysis access fistula in the lower extremity.

Prevention of deep vein thrombosis (DVT) is a key to avoid pulmonary embolism (PE), that is a postoperative fatal complication. Number of patient with postoperative DVT and PE is increasing in Japan with a wide recognition of its pathophysiology.

Screening test is important to find out patients with a thrombophilic redisposition; Protein C deficiency, Protein S deficiency, Anti-thrombin deficiency and positive anti cardiolipin- β2- Glycoprotein 1 antibody. These were examined routinely before major surgery and femoral catheter procedure in Nagoya University Hospital. This paper is a brief summary of these thrombophilic predispositions.

We investigated factors related to the onset, seriousness and clinical manifestations of post-thrombotic syndrome (PTS) by questionnaire to the institutions of a member of Japanese Society of Phlebology. Reports were provided from 40 institutions. The PTS patient of 121 cases during two years was reported. As for the clinical symptom (there is repetition), swelling was recognized most for 86 cases (after the DVT onset, about 3 years later). Venous ulceration was noted in 25 cases (7 years after DVT). Varicose vein was noted in 37 cases (4.6 years after DVT), pigmentation in 46 cases (4.6 years later), and tiredness / pain in 59 cases (2.5 years later). As for the diagnostic procedure, ultrasonography was used in 69 cases and air-plethysmography (APG) was used in 36 cases. Physical examination was applied to 42 cases, and simple Doppler to 38 cases. In addition, for functional evaluation of venous valve, ultrasonography (56 cases) was used most. Clinical manifestation of PTS became severe if a period after the DVT onset is long. It was suggested that time lag of a treatment at the time of the DVT onset, and the management in the chronic stage(long-term wearing of elastic stockings) contributed to the onset and seriousness of PTS.